Equity Case Studies

Equity Case Study: China – Prevention of Parent-to-Child Transmission of HIV Among Vulnerable and Ethnic Minority Populations in Western China

In China, the women at greatest risk of contracting HIV and transmitting it to their babies are often poor, ethnic minorities who live in rural or difficult-to-reach areas.

By Abhijit Shanker

12 October 2012 – In China, the women at greatest risk of contracting HIV and transmitting it to their babies are often poor, ethnic minorities who live in rural or difficult-to-reach areas. Though most vulnerable, they are also least likely to have access to, or to use, maternal-child health care services, including ante-natal care and services to prevent transmission of HIV from parent to child (PMTCT services).

Partnering with China’s Ministry of Health (MoH), UNICEF-China supported interventions designed to facilitate equitable access to PMTCT services for vulnerable women in remote areas of Western China. These interventions included (1) facilitating expansion of integrated PMTCT services into project areas, (2) building capacity for service delivery, as well as uptake by pregnant women living with HIV, and (3) increasing the scope of preventative care to encompass syphilis and hepatitis-B virus, in addition to HIV.

Background

China has a concentrated HIV epidemic. Various subpopulations and certain geographical areas – in particular, ethnic minorities in remote or rural areas – have especially high rates of HIV infection. More than 70 per cent of people living with HIV live in just five provinces: Yunnan, Guangxi, Henan, Sichuan and Xinjiang. Remote areas of three of these provinces – Yunnan, Sichuan and Xinjiang – comprise the project areas for this intervention.

Poor women in rural and ethnic minority areas in these provinces are at high risk of HIV infection. These women also face an array of barriers to accessing HIV testing and treatment for HIV, including PMTCT services. Fear of the social stigma against people living with HIV, speaking Mandarin as a second language or not at all, lack of education, inability to access transportation, and confusion in response to the complexity of PMTCT services all contribute to these most vulnerable women being among the least likely to have access to PMTCT services. Indeed, less than 35 percent of China’s estimated HIV-positive pregnant women currently have access to PMTCT services. As a result, HIV and AIDS affect increasingly large numbers of children in China.

Although PMTCT services are integrated into standard maternal-child health care in China, such integrated service is available in less than 40 per cent of counties. Expanding the coverage area for integrated MCH services – including by building capacity among health care providers to deliver the service, and among pregnant women living with HIV to use the service – will help ensure that the women at greatest risk of contracting HIV have equitable access to PMTCT services and, ultimately, that babies born into impoverished, rural and ethnic minority communities are born free of HIV.

Strategy & Implementation

Cooperating with MoH, UNICEF-China aims through this intervention to eliminate paediatric HIV infection in project areas by facilitating equitable access to, and use of, quality PMTCT services among groups at high risk of contracting HIV and transmitting it to their babies. As the Government of China (GOC) expands integrated MCH services, including PMTCT services, UNICEF-China works to prioritize service delivery in those counties with the highest rates of HIV infection.

Advocacy and social mobilization. UNICEF-China supported advocacy to strengthen the GoC’s policy commitments to equitable access to PMTCT services for China’s most remote and vulnerable populations, including through resource allocations, and by inclusion of syphilis and hepatitis-B virus in the scope of PMTCT services. UNICEF-China also helped develop bespoke communication plans tailored to the specific needs of poor, rural and ethnic minority communities and designed to reduce stigma and mobilize communities around accessing ante-natal care and PMTCT services at earliest stage of pregnancy possible.

Measurement and Evaluation systems and processes. Expansion of China’s integrated PMTCT services with a focus on improving equitable access relies on quality measurement and evaluation data, including data disaggregated by risk factor, gender and age. UNICEF-China contributed to improvements in China’s integrated data gathering, reporting and management, includeing through support for incorporation of PMTCT indicators in national health management systems. In addition, UNICEF-China helped to formulate a framework for using HIV prevalence and other epidemiological patterns (e.g., the vulnerability of individuals to HIV in a community, cost-effectiveness of implementation, and capacity of the local public health systems) to guide implementation of PMTCT services to support equitable access for China’s most vulnerable populations.

Capacity building. Without more and better-trained health care workers, quality PMTCT services will not reach China’s poorest, most remote rural and ethnic minority communities. UNICEF-China promotes capacity building and training to promote early detection, to decrease the incidence of HIV testing during labour, and to improve counseling for pregnant women living with HIV, management of discordant couples, facilitation of necessary follow-up; collection, analysis and use of data; and referrals. UNICEF-China also helps local health care staff to update their knowledge and standardize service provision for preventing transmission from parent to child of hepatitis B virus and syphilis, as well as of HIV.

Progress & Results

The status of the intervention is ongoing from 2011-2015. UNICEF-China is working to exceed the rates of reduction in paediatric HIV infection obtained in past programme cycles. By 2010, transmission rates had fallen below 6 per cent among pregnant women living with HIV who had received HIV tests in UNICEF-China project areas, a transmission rate 30 per cent lower than China’s national average in 2009.

Improved resource allocation. Ensuring delivery of integrated PMTCT services to the communities in China where rates of HIV infection are highest is now a top priority for the GoC, and the national budget for expansion and implementation of PMTCT services exceeds USD120 million.

Improved data collection and utilization. Following successful UNICEF-China projects piloting PMTCT service delivery, the GoC has established a national PMTCT Information Management System (PIMS) to ensure quality disaggregated data that contributes to evidenced-based planning, monitoring and strategic programming. With the support of UNICEF-China, the GoC is also adopting methods for actively identifying cases of HIV through promotion of testing, early diagnosis and accessing treatment, including PMTCT services.

Challenges

UNICEF-China confronted and managed many challenges in this intervention, including the following:

Identifying pregnant women living with HIV in the project area required promotion of HIV testing and accessing ante-natal care. More than 55 per cent of China’s nationwide population of people living with HIV are unidentified, and early detection efforts are still inadequate. Pregnant women too often learn their status during labour and delivery.

Discrimination by health care providers is a barrier that often prevents pregnant women living with HIV from accessing ante-natal care, including PMTCT services. UNICEF-China is engaging in capacity building work to educate health care workers to reduce discrimination and encourage equitable treatment of patients regardless of HIV status.

Mobilising communities to promote use of PMTCT services demands persistence and time commitment in impoverished, remote, poor and ethnic minority communities. Language-appropriate communications campaigns are necessary to raise awareness about available services, including HIV testing, PMTCT services, and subsidies for transportation costs.

Ensuring quality service requires regular capacity building for health care workers to support updating their knowledge and skills relating to the complex and rapidly-changing technical aspects of HIV testing and PMTCT regimes.

Lessons Learned

The most compelling lesson learned from this intervention is that equitable PMTCT service delivery is ultimately dependent on strengthening China’s public health system (including insurance coverage) in impoverished, rural and ethnic minority communities. Inadequate public health infrastructure in project areas, including lack of roads, insufficient public transportation, scarcity of clinics, and too few trained health professionals, prevent vulnerable populations from enjoying equitable access to public health care services generally, and to PMTCT services specifically. Government-underwritten health care coverage for vulnerable populations in project areas must also cover HIV-related costs, including PMTCT services. Quite simply: PMTCT services cannot be integrated into existing maternal-child health care and ante-natal care services in areas where pregnant women do not have access to, or cannot pay for, those basic services.

Next Steps

UNICEF-China anticipates that the near-future development of the initiative will include demonstrating, through data collection and analysis that the community-based communications interventions in project areas have led to greater identification of pregnant women living with HIV and their increasing use of integrated PMTCT services. Based on early intervention results, UNICEF-China will be fine-tuning its programme and working to develop more resources for implementing quality, integrated PMTCT services in project areas.